Spanish experts have proposed a new way of classifying COPD exacerbations that they say may help provide better personalised care to patients.
In a viewpoint in The Lancet, Drs Jose Luis Lopez-Campos and Alvar Agusti said exacerbations were traditionally thought to result from infection, but the causes, consequences and optimal treatments are more complicated.
A worsening of respiratory symptoms – a key to the definition of an exacerbation – can have biological causes, clinical triggers and social influences and might not necessarily be an exacerbation of the underlying disease, they said.
The key was understanding the biology as well as the severity of a patient’s COPD exacerbations, they said.
Exacerbations differ in the extent of the inflammatory response as well as clinical severity, Dr Lopez-Campos explained.
“COPD exacerbations are currently managed by three main treatments: bronchodilators, antibiotics and systemic steroids,” he told the limbic.
“If we assume that bronchodilators are given to every patient with an exacerbation, then the question is when to use antibiotics and/or systemic steroids.”
Currently clinicians use severity signs and sputum purulence to decide which treatment to provide.
“This is too simple a scheme based on subjective items for severity and does not capture the variability in the inflammatory load. A better categorisation of these events is needed,” he said.
They suggest a 2 x 2 matrix of practical treatment recommendations involving a pathobiological and clinical axis.
The pathobiological axis uses appropriate biomarkers and guides medication (use of antibiotics, steroids, or both).
And the clinical axis uses a severity score and defines whether a patient needs hospital admission.
Eosinophilic, low-risk exacerbations can be treated with oral (or high-dose inhaled) steroids and bacterial, low-risk COPD exacerbations can be treated with oral antibiotics.
Eosinophilic, high-risk or bacterial, high-risk exacerbations might need treatment in a hospital, using systemic corticosteroids or antibiotics respectively (or sometimes both, reflecting studies that show synergistic benefits in patients with pneumonia).
The matrix was “admittedly crude” and needs to be researched and either validated or disproved, they said.
However it was intended to stimulate debate and “encourage agreement on the best way to stratify and treat COPD exacerbations in the context of the new precision medicine framework,” they concluded.